Healthcare Provider Details

I. General information

NPI: 1972807865
Provider Name (Legal Business Name): PROGRESSIVE PAIN MANAGEMENT, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 N SHALLOWFORD RD
ATLANTA GA
30338-6308
US

IV. Provider business mailing address

4646 N SHALLOWFORD RD
ATLANTA GA
30338-6308
US

V. Phone/Fax

Practice location:
  • Phone: 770-676-6000
  • Fax:
Mailing address:
  • Phone: 770-676-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006247
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number000186
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number038861
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number038861
License Number StateGA

VIII. Authorized Official

Name: MRS. MARY C LEACH
Title or Position: BILLING/COLLECTION SUPERVISOR
Credential:
Phone: 678-736-6342